HIFU to Treat Refractory Neovascular Glaucoma After Radiation Retinopathy in Eyes with Choroidal Melanoma

Authors: Monica Asencio-Duran1, Cosme Lavin-Dapena1, Beatriz Manzano-Muñoz,1 Oriana D'Anna-Mardero1 and Rosa Cordero-Ros1. 1Department of Ophthalmology, IDIPAZ, Hospital La Paz, Madrid, Spain.

Mail: masedur@hotmail.com. 2014 EVRS Congress - Porto

Purpose:

To report high intensity focused ultrasound (HIFU) circular cyclocoagulation as a new treatment option for uncontrolled intraocular

pressure in patients with uveal melanoma treated with brachytherapy.

Methods

Two patients with unsuccessfully photocoagulated radiation retinopathy after brachytherapy for uveal melanoma and uncontrolled

intraocular pressure on maximal medical treatment were treated with HIFU circular cyclocoagulation. The treatment aims were to

lower intraocular pressure, withdraw acetazolamide oral treatment, and relieve pain due to corneal decompensation.

Results

In both patients, HIFU circular cyclocoagulation permitted withdrawal of oral acetazolamide and relieved ocular pain. Intraocular

pressures decreased from 45 mmHg to 24 mmHg (46,6%) in patient 1 and from 38 mmHg to 20 mmHg (47,3%) in patient 2, and in

both cases IOP decrease was stable for 6 months.

Conclusions

HIFU circular cyclocoagulation may offer a novel option to safely lower intraocular pressure and relieve pain in refractory glauco-

ma associated with uveal melanoma, avoiding the need of secondary enucleation.

Bibliography 1. Jack J. Kanski: Clinical Ophtalmology, 5ª edition, 2004. 2. Yanoff M. Glaucoma mechanisms in ocular malignant melanomas. Am J Ophtalmology. 1970, 70:898. 3. El Baba F, Hagler WS, De La Cruz A, et al. Choroidal melanoma with pigment dispersion in vitreous and melanomalytic glaucoma. Ophtalmology 1988; 95:370. 4. R. Rand Allingham, Shields

JA. Textbook of Glaucoma. Ophtalmology 2005; 21:359. 5. Shields MB, Klintworth GK. Anterior uveal melanomas and intraocular pressure. Ophtalmology 1980; 87:503. 6. Cato S. Ultrasound Circular Cyclo-Coagulation– Innovation in Glaucoma with High Intensity Focused Ultrasound. A report on the satellite symposium ‘UC3, One Giant Step in Glau-

coma with High Intensity Focused Ultrasound’, World Glaucoma Congress, 30 June 2011, Paris

Case 1

• 76 y.o. ♀ treated with I-125 brachytherapy for choroidal melanoma LE in

2005 (15 mm base x 5 mm thickness).

• Medical History: hipercolesterolemia, diabetes mellitus 2, appendectomy,

cholecystectomy, and thrombocytopenic purpura treated with splenectomy.

• Ophthalmic History:

- 2009: LE Phaco, radiation retinopathy treated with focal laser. Vitritis, fi

brine membrane and exudative retinal detachment treated with PPV+ en

dophotocoagulation, capsulotomy.

- 2010: New capsulotomy for pupillary fibrine membrane. ST Triamcinolone

for new exudative RD. 2º Glaucoma treated with a single anti-OHT drop.

- 2011: Ozurdex® is requested but denegated. New ST Triamcinolone for

new exudative RD. 2º Glaucoma (2 drops). New capsulotomy + iridotomy for

pupillary blockage and fibrine membrane.

- 2012: Ozurdex® Inyection

- 2013: New Ozurdex® Inyection. Neovascular Glaucoma with oral acetazola

mide and 3 drops. Painful eye.

• PE: BCVA RE 1, LE 0,1.

• US: tumoral regression (3,9 mm thickness, avascular)

Case 2

• 58 y.o. ♂ treated with I-125 brachytherapy for choroidal melanoma RE in

2009 (7.6mm base x 7.5 mm thickness).

• Medical History: right inguinal hernia repair 11 years ago and cervical os

teosarcoma 16 years ago, smoker until 11 years ago

• Ophthalmic History:

- 2010: RE Vitreal haemorrhage, fibrine membrane and NVG treated

with PPV+ endophotocoagulation and a single anti-OHT drop.

- 2011: RE phaco, following which persisted with elevated IOP (45 mmHg

5 months later), treated with oral acetazolamide and 3 drops.

- 2012: new vitreal haemorrhage

- 2013: posterior capsulotomy and new vitreal haemorrhage.

Neovascular Glaucoma with oral acetazolamide and 3 drops. Painful

eye.

• PE: BCVA RE 0,1, LE 1.

• US: tumoral regression (7,45 mm thickness, avascular)

Day IOP (OD) Treatment Complications/Coments

Prior to treatment 21 mmHg Oral acetazolamide x3 -

1 Day after tt 22 mmHg None -

1 week after tt 32 mmHg None Hyphema

2 week after tt 39 mmHg None Hyphema. Cosopt was indicated.

1 month after tt 18 mmHg dorzolamide hydrochloride-timolol

Hemovitreus

2 month after tt 26 mmHg dorzolamide hydrochloride-timolol

Dellen? Little hyphema.

6 month after tt 20 mmHg dorzolamide hydrochloride-timolol

-

Day IOP (OD) Treatment Complications/Coments

Prior to treatment 31 mmHg Oral acetazolamide x3 Tyndall ++++ in sheet, with hypere-mia ++++ and pain

1 Day after tt 23 mmHg None Tyndall +, painless

1 week after tt 17 mmHg None -

2 week after tt 21 mmHg None Hyperemia

1 month after tt 21 mmHg None No Tyndall, mixed hyperemia

2 month after tt 22 mmHg None Little hyperemia. Topical Fluocino-lone x3 was indicaded

6 month after tt 19 mmHg Timolol x 1 -

Case 1 Case 2

2009

Follow-up

• Ultrasonic Circular Cyclo Coagulation (UC3), is a non-invasive procedure consisting of focal destruction of about less than 40% of the ciliary body by focused

application of ultrasound at 6 points circumferentially for 2 minutes, using the EyeOP1 ®Device (EyeTechCare), which is accomplished under retrobulbar

anesthesia. The high transducer operating frequency (21 MHz), at which energy absorption is High, the total amount of energy required to be delivered to

the eye was low. A decrease of up to 40% of IOP in the treated eye (36% in studies in Spain) can be observed with respect to preoperative values in patients

with refractory glaucoma. We propose this interventional clinical study with UC3 of glaucoma associated with intraocular melanoma to try to control the IOP

in these patients without invasive interventions that could lead to the spread of the disease.